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Chapter 3 | The impact of the crisis on the health system and health in France
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exacerbated by events since 2008, including the need to meet EU fiscal targets
within the Maastricht criteria. Under this pressure, an established set of actors
with health budget responsibility 12 then resorted to a familiar set of technical
tools instead of engaging in more significant and adapted responses. These
technical tools are largely set within the concept of cost-containment strategies,
including accounting measures and incentives for providers to promote the best
medical practice. Hence, the response to the crisis was not specific. There was
no public debate shaping it nor any systematic efforts to set priorities, although
certain measures have been reinforced since the start of the crisis. Likewise, the
sectoral boundaries of the key actors have kept their usual pattern.
5.3 Implementation challenges
The barriers to a more substantial reform are rooted in the institutional
complexity of the French health care system and the conflicts of power and
legitimacy associated with it. Major issues include (1) the relationship between
the state and SHI, (2) the organizational structure and payment system, and
(3) the lack of integrated and comprehensive approaches.
With respect to the first, a 2004 reform clarified the respective fields of
responsibility of the Ministry of Health and SHI. However, the shift of financial
stewardship from the Ministry of Health to SHI is weaker than it could have
been. The Ministry of Health kept the decisions on coverage and pricing for
drugs and devices in house, and the SHI's decision-making power on the rate
of coverage of goods and procedures is further weakened because it is directly
derived from the level of medical benefit assessed by the long-term care system.
Moreover, with regard to professionals' agreements, the government participates
indirectly in the negotiation between SHI and professionals. Professionals'
representatives continue to lobby the Ministry of Health, which retains a strong
role in the negotiations (Chevreul et al., 2010; Ettelt et al., 2010).
Second, the organizational and payment structure of the French health
care system makes the goal of cost-containment more difficult to achieve
than in other national health systems. Indeed, controlling expenditure is a
complicated task when the freedom of consumption by patients and provision
of services by providers is unrestricted, where care is largely publicly funded
and retrospectively reimbursed and where local SHI funds do not have real
financial responsibility but are often described as payers reimbursing care
without having any information on its appropriateness and efficiency. One
12 There is a tradition of joint health budget responsibility between the Ministries of Finance and Health, both chambers
of parliament and a range of other actors including the General Accounting Office (Cour des comptes), the National
Health Conference, and an Alert Committee composed of the Secretary General of the Social Security Accounting
Commission (Commission des comptes de la sécurité sociale), the head of the National Institute of Statistics and
Economic Studies (Institut national de la statistique et des etudes économiques) and an additional expert appointed
by the President of the Economic and Social Council. This constellation of actors has been in place since 2004 and has
not changed during the crisis.